Excelling in Team Based Care-Molly Ekstrand
HB: OK. So today we have a special guest on the Talk to Your Pharmacist podcast. Our guest, Molly Ekstrand is a pharmacist and leader of the medication management program at Park Nicollet Health Services in Minneapolis, Minnesota. Her team of 11 pharmacists has on-site presence in 75% of primary care sites, reaching over 5,000 unique patients each year. And Molly herself practiced comprehensive medication management in internal and family medicine clinics for over 12 years in two different health systems. She understands how to fully utilize the pharmacist in a team-based care model. And now, as we evolve in alternative payment models with so much focus on medication-related health outcomes, she has a passion for working with other healthcare professionals to show how the profession of pharmacy is evolving. Molly, welcome to the Talk to Your Pharmacist podcast!
ME: Thank you. What a great honor to be here. I’m delighted.
HB: Well, thank you for joining us. And now that our listeners have heard a little bit about your background, maybe you can share any gaps from that intro or share a little bit more about your personal life.
ME: I think you did a great job. I’m very passionate about pharmacy and how pharmacy and pharmacists, medication optimization, can really fit in to the value-based area. And I’ve had a lot of fun recently exploring that.
HB: Awesome. Well, we’re here live at the APhA annual meeting in Seattle, and so Molly’s a presenter. She’s got two presentations. But what we’re going to be talking about a lot today is the value proposition for successful ambulatory care pharmacists. And so you know, one of the things, Molly, that I love that you kind of brought up is you can’t be a solution to a problem they don’t have. What exactly do you mean by that?
ME: Sure. So oftentimes, you can read stories, you can read articles on what pharmacists have done to be successful in their particular environments. And so we have to understand that that won’t automatically translate to every pharmacist and every different practice environment. And I have a story about a colleague that I was helping her try to figure out how she fit in. And she honestly had a great idea. She had a great idea for a diabetes-like service where they would produce a sort of report card that would help the patient understand where they were to reaching their diabetes-related goals. And then they would work with the clinic to help educate patients. So I helped her kind of facilitate some of that, and we went to clinic senior leadership, and they looked at her, and they said, “Well, we already do that. And our diabetes quality numbers are great.” So that was just a great example of you can’t be a solution to a problem they don’t have. So my advice to pharmacists when they’re looking at how do I fit, what can I offer that’s something new and different and that someone would see as valuable is to really sit down with the people that you want to work with and see if you can identify some of those pain points, whether they’re practice inefficiencies or quality goals that they’re falling short on or pay-for-performance metrics or readmission rates or care transitions. What are their pain points? And then you can work together to identify that solution.
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HB: I love that. Yes. So just kind of coming up to them with this plan may not be helpful if it’s not one of the things keeping them up at night and is not a pain point for them.
HB: Awesome. So another thing kind of — they want to make sure that, you know, they’re utilizing their resources well. And there’s got to be skin in the game, so it’s not just about revenue. Talk a little bit more about that.
ME: Right. So pharmacist services, it’s really difficult to make it a revenue-generating service because we’re not considered providers in many different states under many different plans. So to actually get reimbursed at an appropriate way to compensate for our salaries is very, very difficult.
ME: So you have to understand with your partner, whether it’s a clinic or a health system or health plan, you have to understand where they have other financial skin in the game. So the reality is for me and my current employer, the charges that we generate, we’re only able to recoup about 20% of that in actual revenue that comes back to our department. And so we have a big negative red budget. So we need to work in the bigger context of where our health system has skin in the game to be able to show how does a pharmacist contribute value to that? And so one example I have is with our next generation NCH renal disease or our dialysis patients, we have an ACO population. And so as a health system, we were performing significantly lower than we should have. So we were losing a lot of money. So as a health system, we said, “OK, how can we band together, make some interventions?” And I said, “Well, hey. Dialysis patients are tremendously complicated, so they take a lot of medications, they’re dose is dependent on their dialysis. They have a lot of side effects often. So how can a pharmacist maybe provide comprehensive medication management services to patients in that population?”
HB: Right. Sure.
ME: And we’ve actually been tremendously successful to the point where we had a senior leader say, “You know what, Molly, it doesn’t matter that we don’t get fee-for-service reimbursement for your visit. But if we save a $12,000 hospitalization and 50% of that comes back to us as the health system, then that’s a financial win for us.”
ME: So by understanding where we have skin in the game, it can really help you be successful.
HB: That makes perfect sense. And as we’re moving from fee-for-service, so being able to charge for each of those things, and moving more toward value-based care, where you’re given a certain amount of risk for each patient, then pharmacists are able to help with more of those cost savings and reducing readmissions or picking less costly medications. I mean, just so many different opportunities and just like your example with the dialysis patients. So yeah, that makes perfect sense. So you know, now we’re kind of moving on towards all of this team-based care and patient-centered care. How should pharmacists approach that team-based mentality?
ME: One analogy that I love to use when I talk about team-based care is why would you want a baseball team full of pitchers? Right?
ME: So you have all these different positions on a baseball team, and they’re all really important. They have some cross-collaboration, right?
ME: Like all the people on a baseball team know how to bat, they know how to throw the ball. But they all have their certain spots on the field, and they all play a specific role. So as we think about our different care team members, we have to think about the different skill sets that they have, the different training that they have, the different perspectives they have from where they’re at on the baseball field, for example, and how do we play together in that environment? So as pharmacists, I feel it’s really important that we have to offer something unique and different, that no one else on our healthcare team can offer. And that’s when we’re going to be successful.
ME: So we also need to work together as a team to manage how we message to patients that we’re working together.
HB: Sure. Yeah. Because so many times, the patient’s like, “No, my doctor went over my medicine.” Or “No, why do I need to see the pharmacist?” And I remember last year at APhA, one of the presentations was we created a brochure that described what the patients would expect to see from a pharmacist’s visit. And yeah, I think that’s so true. Like even with the whole Pharmacists for Healthier Lives, just doing a better job on educating all of the services that pharmacists can do.
ME: Right. And similarly, when I as a pharmacist want to refer a patient to a care coordinator or when I want to refer them to a dietician to jump more into their diabetes diet, then that’s important that I message that we work very closely together and here’s what we offer that’s different. But also that, “Hey, Hillary and I are going to talk after you guys meet so I know what you came up with and what you decided for your care plan.”
ME: We’re all a team for you.
HB: Yes. That makes perfect sense. OK. So great, we’re all on the team. And you know, how do we show that pharmacy is indispensable or an irreplaceable part of that team?
ME: Right. So I talk a lot about how you can’t be just a nice, extra, add-on service. If we’re just doing a one-time consult, polypharmacy, we’re making a few suggestions to the clinician or to the physician partner, and then we’re done, that’s kind of a nice add-on service but very easy to disappear, potentially. Right? And so as you think about, you need to integrate yourself as a cog in that wheel.
ME: So if you’re gone, that whole system is not going to work as efficiently.
ME: And what we’ve done is we’ve tried to adopt a lot of different collaborative practice agreements. So we have a pharmacist scope of practice. And even though we provide comprehensive medication management, we do have health condition or disease-specific protocols that we can use to adjust medicines, initiate medicines and really positioning ourselves as being able to provide real-time patient care, make patient-specific clinical decision-making regarding drug therapy. And that’s something that our nurse partners can’t do, and that’s something that will very nicely complement what our physician partners are doing as well.
HB: Yeah. And you know, now we’ve got some great articles that have come out that support that exact thing, so Harvard Business Review and then the New York Times both in January, put out these like “The Unsung Role of the Pharmacist,” and Harvard Business Review really focused on how a pharmacist has this unique skill set to help when patients are non-adherent. And it’s a very individualized reasons, and pharmacists have this great skill set to be able to do that comprehensive medication management, get paid for those services, and help with that huge $100-300 billion issue of non-adherence.
ME: Right, right.
HB: It’s just so crazy.
ME: Well, and to talk about adherence, that’s kind of a pain point for me, right?
ME: So if we think about the comprehensive medication management model where you’re really assessing indication effectiveness, safety and convenience, and the last step is the adherence, right? The adherence convenience. So we really want to emphasize optimizing medications because it’s not enough — I can’t start with adherence because if the medicine isn’t effective for you, if it’s not safe for you, I honestly don’t want you taking it.
HB: Exactly, yes. That’s such a good point.
ME: Another thing that I think pharmacists really excel at is really understanding the behavioral aspects to taking medications and the experiences, the medication experiences that our patients convey in sometimes very subtle ways that I think a pharmacist has a keen ability to really pick up on that and help a patient navigate those thoughts and feelings regarding taking medications in their everyday life.
HB: Definitely. So what advice would you give for the pharmacy profession to really help excel in the quality and cost gain?
ME: I would say, I would suggest try to get a seat at the table. Try to start conversations so you can understand what are the priorities of the people that you want to partner with. Do some research on, you know, the different ACO and value-based purchasing models. It’s really helpful to read publications on what other pharmacist colleagues have done but also keeping in mind that it may not be the solution to a problem that your partner, your future partners, don’t have, so to keep that in mind. But keep talking. I think we do a great job of promoting pharmacists within pharmacy, but we need to branch out and promote ourselves to the greater public, whether that’s patients and policymakers or whether that’s our healthcare colleagues as well.
HB: Definitely. Yeah. Great advice. So Molly, as our final question, what is some advice that you would share with your younger self or for other pharmacists who are just getting started in their career?
ME: That’s a great question. I’ve had a wonderful career path that’s been really innovative. And I think when I graduated, I didn’t have in my mind this whole practice of ambulatory care pharmacy really didn’t exist. I have a passion for working with patients and the patient experience, but I had no idea that my career would lead in this direction and that I would be so passionate about it. I would suggest to my younger self or younger colleagues to stay involved with your professional organizations and that that’s created so many wonderful avenues and connections for me. Get out there. Volunteer. Say yes to things. Stretch your brain a little bit, and try new things that are going to enhance your skill sets and develop yourself professionally.
HB: Awesome. Well Molly, thank you so much for being a guest on the Talk to Your Pharmacist podcast.
ME: Thank you.
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